Business form



J. L. HOWARD.

BUSINESS FORM.

APPLICATION FILED MAR. 14, 192l.

1,40 ,5 1, Patented Feb.1 4, 1922.-

The Travelers Insurance Company Hartford, Connecticut CERTIFXCATE A Hereby Agrees t6 Issue Life insurance te N" for the largest sum stated on any coupon remaining hereto attached, provided he will sign the attached apphcntion and pay to the agent hereinafter named the prer'nium for the form and Amount of insurance selected according to the premium rates set forth in the rate bank of the Company.

The Company hereby author M PM to place this insurance in force lmmedlotely upon payment of the premium so determined,- I

Depadmenffixmta/yt Received. of the applicant herein named the annual premium of (Q) Dollars upon th form of contract,

payable to as beneficiary. Insurance in the amount selected as hereinbefore described shall be in force from the date of such payment ascertified. hereon for the period covered lay such premium; subsequent payments to be made according to the term: ofaaid. contrqct.

Cutnncn: om: Ann-r Department Seam/7 VOID UNLESS CERTIFIED BY THE AGENT HEREIN NAMED WYI'HIN IXTY DAYS FROM INSYRUCTJOH-i: Ifnot certified within fhaf period return til/l: czrH/ica/e immediately thereafter to the Company for (anze/almn. If certified tear lrallght zeros; an per/oralcd line below coupon which show: in left hand talumn tile gmaunt of Insurance Jeleczed Deliver upper porfion to Inez/red. Return lown' porzlon to Company for lssaanze afcomracfi ONE THOUSAND DOLLARS COUPON N04 1 TWO THOUSAND DOLLARS COUPON N9. 2 ONE THOUSAND DOLLARS TWEN'W'FIVE HUNDRED DOLLARS GOUPONlNn-ZX. TWO THOUSAND DOLLARE:

THREE THOUSAND DOLLARS- COUPON N0. 3 TWEN'l'Y-FIVC HUNDRED DOLLARS FOUR "FHOUSAND DOLLARfi I z? COUPON NO- 4 THREE THOUSAND DOLLARS FIVETHO SAND DOLLARS u COUPON N0. 5 FO R THOUSAND L JLLAKS D filX THOUSAND DOLLARS COUPON No. 6 FIVE HOUSAND DOLLARS SEVCN THOUSAND DOLLAR: COUPON NA 7 SIX THOUSAND DOLLAR: SEVEN V- FlVE HUNDRED DOLLARS COUPON lief/)1 SEVEN THOUSAND DOLLARS EIGHT THOUSAND DOLLARS COUPON N0- 5 SEVENTV- F VE HUNDRED DCLLAR5 NINE THOUfi ND DOLLARS COUPON NO. 9 EIGHT THOUSAND DOLLARS TEN THOUSAND DOLLARJ COUPON Ne. 10 NINE THOUSAND DOLLAR COUPON H0- 11 TEN HOUSAND DOLLARS NUMBER h l t Th Tr lers Insurance Compan for Life lnsurnnoe for the gnallesl: Amountetated L1 i cwzn ;e|nal ning lseveto nttachedkpurmht to the terms and cond\t|ons vf an application for Ii Insurance in accnrdance with w ich there has been Issued to me Life Contract No.

I certify that aim-0 making suth application I have not received medical ovsi rgiul attention, and that there has been no change in my personal or funily history. C I desir payable to Agent form of contract a: beneficiary.

I further declare that l. have paid to Dollars ammfm.

Dafe VOID UNLESS EXECUTED WlTHlN SlX'lY DAYS FROM JAMES L. HOWARD, 0F HARTFORD, CONNECTICUT, ASSIGNOR r0 THE TRAVELERS INSURANCECOMPANY, or HARTFORD, CONNECTICUT, A CORPORATION or coN-j NEC'l IGUT.

To all whom it may concern: a Be it known that I, JAMES L. HOWARD, a citizen of the United States, and resident of Hartford, county of Hartford, State of Connecticut, have invented certain new and useful Improvements in a Business Form, of which thefollowing is a specification.

This invention relates to a novel and useful formfor transacting business; Theinvention finds a peculiar usefulness in c011- nection with the insurance business and for purposes of the disclosure in this application of the invention and itsmethod of use, tlie des cription will be directed to an insurance form, suclifas "is illustrated in the draw ing, and in which the invention is embodied, In the solicitatlon and sale of life insurance at the present time, and assuming that an agent has sold a pohcy of insurance to an applicantfor insurance, it is a customary practice. for the agent to request the issuing company to prepare a second policy "Upon delivery of the" original policy, the

agent offers to the insured this additional policy and the insured is given a period of sixty days within which to decide whether or-not he will accept the additional policy. In a certain percentage of cases, such poli-- cies are accepted, but in a very large percenta 'e of cases such policies are not accepted because theinsured may desire a different form or amount which, without the use ofthe proposed certificate, the agent is not able to grant without submission to the executives of the company The time consumed in preparing these extra policies which are not used is an item of considerable moment, and the insurance form constituting the subjectmatter' of this invention is intended to largely reduce or eliminate the waste involved,--While, at the same time, giving tothe agent and to the insured an opportunity to make such a contract as may then be agreed upon without beingjrestricted to any particular i'orm oramount.

Generally speaking, the insurance form constituting the subject matter of this invention as sent to the agentby the issuing company constitutes an authorization by the company, through the signature of a proper OlllClZll, of the agent specified, to close a contract 'of insurance with the insured,

Specification of Letters Patent.

BUSINESS FORM.

Patented'Febi 14, 1922.

Application filed March 14, 1921. I Serial No. 452,018.

who is specifiedyfor any amount ofinsur-l ance between limits established by the company on the form. The agent is thus, left.

freeto negotiate the sale of any of thedif ferent forms of policies issuedby the coInpany and the insured is left free, to select,

theform desired, to specify how muclradditional insurance he wishes to purchase, and to indicate who Y i Y and in all of these additional insurance original policy upon insurance is based.

respects the policy-of which this additional This invention then resides in an insurance form of peculiar construction'and arrangement comprising three sections em-, bodied in asingle sheet which shall be seven able in onethe intermediate-section, and so arranged that each section shall constitute a check on the other section as to at leastonecondition of the policy to beissued, for instance the amount of'the policy, this checli being automatically established by the severance of the form. The two parts of the form when severed will each carry corre sponding indications as to the form of insurance contract which is desired, the amount of the premium, and the beneficial (some or. all of these features of the insurancecontract may be endorsed on the two parts of the form). Before proceeding to a detailed do scripti'on of the particular form here select edfor purposes oi illustration, it may be said that the device forming the subject 1natter ofthisinvention maybe adapted ,to other.

uses than in the field of insurance and that shall be the beneficiary,

V 1 may vary from the things than the amount ofthe insurancepolicy involved, and further, that thisautomatic check may bejapplied to morethan a single feature of the transaction,whieh in the case'illustrated is the sale ofinsurance.

The drawing illustrates the application of" the inventionto a form which may be uti{ lized in connection with the sale of an'insurance policy. As will be seen, the form is inrthree sections which may be generally indicated by the reference lettersA, B and C. The upper section is the agreement by the company to issue insurance to the in sured, John Doe, and authorizes the agent, Richard Rowe, to place the, insurance. in force under certain conditions with blanks left for the indication of the amount of the rot premium, the amount of insurance, the form of the contract, and; the beneficiary. A blank is-also left for the certification by the agent which will put the insurance in force as and of the date written. This upper section contains, as in the upper right hand corner,-

a certain certificate'number.

The intermediate section B comprises a plurality of coupons with perforations between .in order that the complete form may be readily severed at any desired point, The borders D are notfperforated and'thus guard. against accidental severance of the form'orfl anylpart' ofit. In the'case illustrated, these coupons have a central column in which each coupon is numbered, and' at each side of this central column there is a' column representbe' observed that in the left hand column of coupon No. 1 there is an indication of $1,000,

'seen that the left hand column indications of each coupon are the same'in amount as theright hand column indications of each succeeding coupon. That is to say, the left hand column indication ofcoupon No. 1 is $1,000 and the right hand column indication of coupon No.2is $1,000; the left hand column indication of coupon No. 5 is $5,000 and the right hand column indication of coupon No. 6 is $5,000. It will thus be ap parent that wherever in the intermediate section B the form is severed the largest amount shown on any coupon attached to. the upper portion will correspond to the smallest amount shown on any coupon attached to the lower portion. When severed,ftl11e u perportion is to be delivered to the insured and the lower portion sent to the home ofiice. The third section of the form constitutes,

in' this case, an application for life insurance which is to be signed by the applicant who is the individual whose name appears at thetop of the form and to whom the company'agrees to issue a policy under certain conditions.

cate number as appearsin the upper right hand corner of section A of the form and" contains blanks to indicate the form of contract desired, the nameofthe beneficiary, the

declaration of the payment of the premium to the agent whose name'appears at the top of the form, and provisions for the signature of'the applicant, witness, etc.

riefiy, the method of use of this form. in

the insurance business is as follows. Theing in the case illustrated, dollarsQ It will I This application, as in the up per right hand corner, bears the same certifiagent, Richard Rowe, having sold a policy of insurance to'John Doe receivesifrom the company oneof these forms properly numbered and containing only the nameofthe lIlSUTGClpt-llli 11211116 of the agent, and the signature of the proper company oiiicial. This constitutes an authorization of the agent to put, in force a policy, of insurance limited only in the'maximum amount of the policy which is indicated by the largest-amount shown on any coupon. If the insured desires'morefinsurance, (it maybehad without further medical examination, etc.,'fif taken within the sixty days which is usually 7 allowed in this business) he indicates to the agent the form of contract'hedesires, and

the nameof the beneficiary. Theseitems are I filled in both in the upper part of the form,- section A., under the receipt and in thellower part of the form, section C, which constitutes the application, the agent then severs. this formin the intermediatesection B under the couponwhich, intheleft handcolumn, shows the amount of insurancewhich the insureddesires to buy. If the policy is to tear $5,000, the form is severed below coupon No. 5.Y:The upper'portion is then delivered to the insured and represents all of the details of the proposed policy and the l largestfamount on: any couponindicates the amount for which the face o-fthe policy is to be written. The lower part is returned to the company as its guide inpreparing the. complete policy, and other facts as to the policy, to wit the form of the contract and the beneficiary having been written into the application, the amount for which the policy is to be written will be found to be the smallest amount represented on anylcoupon attached. I V

Ic'lainr as my invention T V v1 In; a lifeinsurance form, a sheet comprising three sections, the upper of said sections comprising a certificate bearing a con: ditional offer to an insured,an authorization to an ao'en-t, a,receipt, and an'appropriately designated ,certificate date and signature line;;the lower of said sections comprising an application for insurance as offered in said certificate section; saidiipper and lower sections bearing like provisions for limiting the smear acceptancelof the 'oflfer of insur ance, .and identical serial numbers; and an intermediate section comprisingr a plurality of coupons with indicated lines ofseverance between them'fand indications of amounts of dollars on said coupons so arranged that when adjacentcoupons are separated along the line of, severance therebetween the amounts on said adjacent coupons auto matically establish acheck as to the amount of insurance agreed upon. i i i 2. In a life insurance form, a sheet comprising three sections, the upper of said sections comprising a certificate bearing a con ditional offer to an insured, an authorization to an agent, a receipt, and an appropriately designated certificate date and signature line; the lower of said sections comprising an application for insurance as offered in said certificate section; said upper and lower sections bearing like provisions for limiting the time of acceptance of the offer of insurance, and identical serial num- 10 bers; and an intermediate section comprislines of severance between them and indieav tions of amounts of dollars on said coupons,

an amount on any given one of said coupons corresponding to an amount on the next preceding coupon and a second amount on said given coupon corresponding to a like amount on the next succeeding coupon.

JAMES L. HOWARD 

